Clinical Documentation RCC Community Health Worker Class Heather Hartman

Introduction to SOAP Notes  S – Subjective  O – Objective  A – Assessment  P – Plan

Subjective  This is where you put what the individual has said about their health or issues Includes:  When did the symptoms start  Are symptoms better or worse since onset, episodic, variable, constant, etc  What are the symptoms like? Sharp, dull, etc  How severe are they  What aggravates/reduces the complaint – activities, postures, drugs, etc.  Additional symptoms  What types of treatments has the person tried?

Objective  Here you have the measurable, repeatable, and traceable facts about the person’s status. Could include:  Vital signs  Findings from physical examinations, such as posture, bruising, and abnormalities  Results from laboratory  Measurements, such as age and weight of the patient

Assessment  Document changes you see in the individual.  Record any new information that healthcare professioonals pass along to you. Be sure to include any information regarding specific changes in the individual’s status (medical or non-medical).  If you are performing any specific assessments, i.e. Environmental Assessment, the results would go here.

Plan  Here you will outline your plan for working with the member. It is an opportunity to include them in person centered care.  What are the recommendations and follow-up tasks for both yourself and the individual you are working with?

Group Apple Exercise In a group- On a separate piece of paper, write down detailed description of your apple. Use your observational skills and senses. Be as specific as you can.

Class Discussion Review apple descriptions

Discussion  What kind of information did you need to take in in order to write your discussion?  When we identified each group’s description:  What information helped?  What information didn’t help?  What would you have changed about your own description?  What would you have done differently if you knew someone else would be reading/hearing your description?

Importance of Clinical Documentation  If you don’t document it, it didn’t happen  Allows you to track outcomes and improvement of the individual  Allows you to follow the “Golden Thread”  It is a communication tool with your team  Payers require that document of patient visits exist  It serves as a legal document  Impacts coding, billing, and reimbursement.

Fraud, Waste, and Abuse  Fraud is generally defined as knowingly and willfully executing, or attempting to execute, a scheme or artifice to defraud any health care benefit program or to obtain (by means of false or fraudulent pretenses representations, or promises) any of the money or property owned by, or under the custody or control of, any health care benefit program. (18 U.S.C. § 1347)  Waste is overutilization of services or other practices that, directly or indirectly, result in unnecessary costs to the health care system, including the Medicare and Medicaid programs. It is not generally considered to be caused by criminally negligent actions, but by the misuse of resources.

Fraud, Waste, And Abuse Continued Abuse includes any action(s) that may, directly or indirectly, result in one or more of the following:  Unnecessary costs to the health care system  Improper payment for services  Payment for services that fail to meet professionally recognized standards of care  Services that are medically unnecessary  Abuse involves payment for items or services when there is no legal entitlement to that payment  It can include not knowingly and/or intentionally misrepresented facts to obtain payment.  Abuse cannot always be easily be identified. The difference depends on the specific facts and circumstances, intent, and prior knowledge of the individual billing for the services.